Has laparoscopy changed the surgical approach in gastroesophageal reflux? Apropos of an experience with 63 cases of gastroesophageal reflux treated by laparoscopy

INTRODUCTION: Indications for surgery in gastrooesophageal reflux disease (GERD) have decreased significantly since the introduction of proton pump inhibitors. At the same time there has been renewed surgical interest in this disease triggered by the development of laparoscopy. We present our results with laparoscopic treatment of GERD and the change in our surgical approach to the condition during the past few years. METHODS: All patients admitted to the surgical department underwent prior evaluation by a gastroenterologist. Indications for surgery were resistance to medical therapy in 30 cases, recurrence of GERD after cessation of treatment in 25 cases and personal preference of the patient when maintenance therapy was necessary in 6 cases. The data were reviewed and the patients contacted during the first trimester of 1998 to evaluate long-term results. RESULTS: 63 patients were operated on between 1991 and July 1997. Rossetti-Nissen fundoplication was performed routinely until March 1995. Thereafter, the type of antireflux surgery has been chosen according to the preoperative evaluation of the patients, including endoscopy, oesophageal manometry and gastric emptying studies. There was no mortality and, except for one case, only minor morbidity. Four patients required reoperation, two for severe gas bloat syndrome and two for recurrence of GERD. Overall, the long-term follow-up shows that 93 patients are satisfied or very satisfied with their outcome (Visick 1 or 2). 5% of the patients need daily medication for heartburn, 5% complain of occasionally disturbing dysphagia, and 12% of sometimes distressing gas bloat. More patients have gas bloat after the Rossetti-Nissen procedure than after the Nissen or Toupet fundoplications. CONCLUSIONS: The enthusiasm of surgeons for the laparoscopic approach to GERD has prompted renewed interest in the pathophysiology of the disease. Consequently, indications for surgery are better defined, surgical technique is chosen according to the individual patient based on objective preoperative studies and follow-up has improved. In this setting, laparoscopic fundoplication represents an effective treatment for GERD. It is associated with lower postoperative morbidity than open surgery and represents the first choice when surgery is indicated.